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Pediatric Gastroenteritis in Emergency Medicine

Practice Essentials

Though often considered a benign disease, acute gastroenteritis remains a leading cause of pediatric morbidity and mortality around the world, accounting for 533,800 deaths annually in children younger than 5 years (higher than other well-known diseases such as malaria, HIV & TB for the same age group).
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Child with sunken eyes.

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Viruses remain by far the most common cause of acute gastroenteritis in children, both in high-resource and low-resource settings, though several bacterial species also play an important role in acute gastroenteritis, especially in low-resource settings. The two primary mechanisms responsible for acute gastroenteritis are as follows:

Damage to the villous brush border of the intestine, causing malabsorption of intestinal contents and leading to osmotic diarrhea

Toxins that bind to specific enterocyte receptors and cause the release of chloride ions into the intestinal lumen, leading to secretory diarrhea

Signs and symptoms

These include the following:



Increase or decrease in urinary frequency

Abdominal pain

Signs and symptoms of infection – Presence of fever, chills, myalgias, rash, rhinorrhea, sore throat, cough; these may be evidence of systemic infection or sepsis

Changes in appearance and behavior – Including weight loss and increased malaise, lethargy, or irritability, as well as changes in the amount and frequency of feeding and in the child’s level of thirst

History of recent antibiotic use – Increases the likelihood of Clostridium difficile

History of travel to endemic areas

Assessment of dehydration

According to the World Health Organization (WHO), a patient exhibiting 2 of the following signs can be considered to have some amount of dehydration:

Restless, irritable

Sunken eyes

Thirsty, drinks eagerly

Skin pinch goes back slowly

According to the WHO, a patient exhibiting 2 of the following signs can be considered to have severe dehydration:

Lethargic or unconscious

Sunken eyes

Not able to drink or drinking poorly

Skin pinch goes back very slowly

See Clinical Presentation for more detail.


Workup in pediatric gastroenteritis can include the following:

Baseline electrolytes, bicarbonate, and urea/creatinine – In any child being treated with intravenous fluids for severe dehydration

Fecal leukocytes and stool culture – May be helpful in children presenting with dysentery

Stool analysis for C difficile toxins – In children older than 12 months with a recent history of antibiotic use

Stool analysis for ova and parasites – In patients with a history of prolonged watery diarrhea (>14 days) or travel to an endemic area

Complete blood count (CBC) and blood cultures – Any child with evidence of systemic infection

If indicated, urine cultures, chest radiography, and/or lumbar puncture should be performed. Several studies have found that combinations of clinical signs and symptoms may have better sensitivity and specificity for detecting dehydration in children than do individual signs or symptoms.

See Workup for more detail.


Oral rehydration solution

The American Academy of Pediatrics, the European Society of Pediatric Gastroenterology and Nutrition (ESPGAN), and the World Health Organization (WHO) all recommend oral rehydration solution (ORS) as the treatment of choice for children with mild to moderate gastroenteritis, including those in both high-resource and low-resource settings, based on the results of dozens of randomized, controlled trials and several large meta-analyses.

Pharmacologic therapy

Agents used in the treatment or prevention of acute pediatric gastroenteritis include the following:

Probiotics – As probiotic preparations vary widely, it is difficult to estimate the effectiveness of any single preparation. Evidence is mixed for the effectiveness of some probiotics. 

Zinc – To treat diarrhea;
the WHO and two systematic reviews support (with moderate evidence) zinc supplementation for all children younger than 5 years with acute gastroenteritis in low-resource settings, though little data exist to support this recommendation for children in high-resource settings

Metronidazole and Tinidazole – first-line drugs- In patients infected with C difficile and Giardia

Tetracycline and doxycycline – For cholera (azithromycin should be used for children younger than 8 years)

Vaccine – In February 2006, the US Food and Drug Administration (FDA) approved the RotaTeq vaccine for prevention of rotavirus gastroenteritis

See Treatment and Medication for more detail.

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